Hypoalbuminemia and the Higher Risk of Perioperative Sentinel Adverse Events in Patients Undergoing Total Shoulder Arthroplasty: A Propensity Score Matched Analysis

Document Type : RESEARCH PAPER


Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland, USA


Background: The purpose of this study is to examine the effect of hypoalbuminemia (HA) on sentinel adverse events
after total shoulder arthroplasty (TSA).
Methods: Patients who underwent primary TSA from 2015-2018 were collected from the National Surgical Quality
Improvement Program (NSQIP) database. Patients with HA (serum albumin < 3.5 g/dL) were compared to patients with
normal serum albumin. A probit regression model was used to estimate a propensity score. Logistic regression was
performed to evaluate the effect of HA on sentinel adverse events after surgery.
Results: A total of 4,337 patients were included, 8.2% of patients had HA. Patients with HA had higher rates of
sentinel adverse events (14.0% vs 5.5%, P<0.01) compared with patients who had normal serum albumin. Reoperation
(4.5% vs 1.5%, P<0.01), readmission (11.2% vs 3.9%, P<0.01), urinary tract infection (0.8% vs 0.03%, P<0.01) and
pulmonary embolism (1.1% vs 0.2%, P=0.01) were higher in patients with HA. The odds ratio for a sentinel event for
patients with HA was 2.6 (95% CI: 1.54, 4.44, P<0.01) when compared to a propensity score-matched control group.
Conclusion: Patients with HA are at increased risk of sentinel adverse events following TSA compared to patients with
normal serum albumin levels.
Level of evidence: II


1. Busher JT. Serum albumin and globulin. In: Clinical
methods: the history, physical, and laboratory
examinations. 3th ed. Walker HK, Hall WD, Hurst
JW,eds. Boston, MA: Butterworths; 1990.
2. Bohl DD, Shen MR, Kayupov E, Valle CJD.
Hypoalbuminemia independently predicts surgical site
infection, pneumonia, length of stay, and readmission
after total joint arthroplasty. J Arthroplasty. 2016;
31(1):15-21. doi: 10.1016/j.arth.2015.08.028.
3. Black CS, Goltz DE, Ryan SP, et al. The Role of
Malnutrition in Ninety-Day Outcomes After Total Joint
Arthroplasty. J Arthroplasty. 2019;34(11):2594-2600.
doi: 10.1016/j.arth.2019.05.060.
4. Wilson JM, Lunati MP, Grabel ZJ, Staley CA, Schwartz AM,
Schenker ML. Hypoalbuminemia Is an Independent
Risk Factor for 30-Day Mortality, Postoperative
Complications, Readmission, and Reoperation in the
Operative Lower Extremity Orthopaedic Trauma
Patient. J Orthop Trauma. 2019;33(6):284-291. doi:
5. Sloan M, Sheth NP, Nelson CL. Readmission and
reoperation following primary total knee arthroplasty
in patients with obesity and hypoalbuminaemia.
InOrthopaedic Proceedings 2019 Oct (Vol. 101, No.
SUPP_11, pp. 15-15). The British Editorial Society of
Bone & Joint Surgery.
6. Rana AJ, Bozic KJ. Bundled payments in orthopaedics.
Clin Orthop Relat Res 2015; 473(2):422. doi: 10.1007/
7. Lucas DJ, Haider A, Haut E, et al. Assessing readmission
after general, vascular, and thoracic surgery using
ACS-NSQIP. Ann Surg 2013; 258(3):430. doi: 10.1097/
8. Lucas DJ, Pawlik TM. Readmission after surgery. Adv
Surg 2014; 48:185. doi: 10.1016/j.yasu.2014.05.009.
9. Bozic KJ, Ward L, Vail TP, Maze M. Bundled payments
in total joint arthroplasty: targeting opportunities for
quality improvement and cost reduction. Clin Orthop
Relat Res 2014; 472(1):188. doi: 10.1007/s11999-
10. Yuwen P, Chen W, Lv H, et al. Albumin and surgical
site infection risk in orthopaedics: a meta-analysis.
BMC Surg. 2017; 17(1):7. doi: 10.1186/s12893-016-
11. Kishawi D, Schwarzman G, Mejia A, Hussain AK,
Gonzalez MH. Low Preoperative Albumin Levels
Predict Adverse Outcomes After Total Joint
Arthroplasty. J Bone Joint Surg Am 2020;102(10):889-
895. doi: 10.2106/JBJS.19.00511.
12. Lu Y, Khazi ZM, Patel BH, et al. Big Data in Total
Shoulder Arthroplasty. J Am Acad Orthop Surg. 2020;
28(14):e626-e632. doi: 10.5435/JAAOS-D-19-00173..
13. Pugely AJ, Martin CT, Harwood J, Ong KL, Bozic
KJ, Callaghan JJ. Database and Registry Research
in Orthopaedic Surgery. J Bone Jt Surg. 2015;
97(15):1278-1287. doi: 10.2106/JBJS.N.01260.